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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001680
Report Date: 03/13/2024
Date Signed: 03/13/2024 01:48:57 PM

Document Has Been Signed on 03/13/2024 01:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ELK GROVE SPRING HOMES INC.FACILITY NUMBER:
347001680
ADMINISTRATOR:TEJADA, CARMENCHITAFACILITY TYPE:
735
ADDRESS:8720 SECKEL CT.TELEPHONE:
(916) 686-5547
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
03/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Clifford TejadaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 3/13/24 at 8:45a. LPA met with Clifford and Carmenchita Tejada and stated the purpose of the visit.

LPA conducted interviews of Staff #1 (S1-S5) during this visit.

LPA obtained copies of the following: postings of Administrator Certificate for Clifford Tejada, 2024 Minimum Wage Changes, LIC500 Personnel Report for May 2022, May 2023, and January 2024, Guardian roster, LIC309 Administrative Organization, LIC308 Designation of Facility Responsibility, Residential Service Contract Agreement w/Staffing Schedule Requirements, Payroll Journal for 1/2023 - 3/2024, Direct Care Staff Schedule, Staff Work Schedule for May 2023, Determining Direct Care Staff Hours: Basic Staffing Level and Additional Hours, Register of Facility Client/Resident (LIC9020), Consumer Day Program Contact Information for all clients, Organization Chart. LPA also took pictures of the food and drinks in 3 refrigerators and 1 freezer and cabinets in the facility as well as the Minimum Wage poster. LPA observed the area that is prepared for staff as a rest area, however, there is no live-in staff.

Based on a review of the documents provided, photos, and interviews conducted, LPA did not observe a violation of the Labor Law Requirements at this time.


Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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